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Center for Substance Abuse Treatment. Intensive Outpatient Treatment for Alcohol and Other Drug Abuse. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1994. (Treatment Improvement Protocol (TIP) Series, No. 8.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Intensive Outpatient Treatment for Alcohol and Other Drug Abuse.

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Chapter 3—Components of an Effective IOT Program

Recent developments in the field of alcohol and other drug (AOD) abuse treatment, along with a prevalent interest in and awareness of the effectiveness of the intensive outpatient treatment (IOT) level of care, have promoted the growth of IOT programs. This chapter primarily addresses services that are considered essential to any IOT program, as well as services that can be described as optimal. The chapter includes a review of the salient clinical issues and characteristics of IOT. A framework for considering IOT programs, rather than an exhaustive clinical explication, is presented. Although the needs of special groups (such as clients with dual disorders, pregnant women, elderly people, and gay men and lesbians) are not specifically addressed in this section (see Chapter 5), the services described here can be adapted for programs that specialize in meeting the needs of these and other groups.

Rationale

Traditional outpatient treatment generally consists of individual or group counseling. This approach is not sufficiently intensive to meet the needs of patients with moderate to severe AOD disorders, since clients engage in therapy sessions only once or twice a week. Traditional outpatient treatment usually offers fewer types of treatment services than IOT and is generally not organized to address the multidimensional needs of AOD-dependent patients.

At the other end of the spectrum of treatment intensity is inpatient treatment: medically managed intensive inpatient treatment and medically monitored intensive inpatient treatment. These two levels of care involve an organized service of around-the-clock evaluation, care, and treatment in an inpatient setting. In this setting, patients who have severe withdrawal, and/or medical, emotional, or behavioral problems can receive primary medical and nursing services.

IOT represents an approach to addiction treatment at a level of intensity that is intermediate between intensive inpatient treatment and traditional outpatient treatment. Chapter 2 includes a discussion of the levels of care. When clients are appropriately placed, IOT provides a level of effectiveness at significantly less expense that is equivalent to the effectiveness of inpatient programs. IOT has significant advantages as a level of care organized to treat clients with moderate to severe AOD disorders. These advantages can be recognized in terms of cost, attractiveness to patients, and clinical efficacy.

Advantages

Financial and Cost Benefits

AOD abuse has been shown to have a tremendous economic impact on society. The Institute of Medicine estimates that the annual total cost to society of alcohol problems is $117 billion. However, less than $10 billion is spent annually on total treatment costs for alcohol problems (Institute of Medicine, 1990), a negligible amount when compared with the costs to society. However, in an era of health care reform, the AOD treatment field has the same commitment as other health care fields to cost-efficient quality care. Within the context of a continuum of care, IOT is an example of innovative change contributing to the attainment of the national objective of reducing the costs of health care.

The bulk of AOD abuse costs relate to morbidity, mortality, and crime. Additional costs are for support services and treatment for fetal alcohol syndrome, acquired immunodeficiency syndrome (AIDS), and other medical comorbidity, as well as services to persons living with someone who has an AOD disorder.

One of the only clear and consistent indicators of positive AOD treatment outcome is the length of time an individual is involved with AOD treatment services. Treatment in an intensive outpatient setting can be provided for many more weeks than in an inpatient setting, and at significantly less cost. Further, studies in which traditional 28-day inpatient treatment programs for AOD abuse have been compared with IOT have demonstrated comparable clinical outcomes (Fink et al., 1985).

Cost savings are also realized in IOT programs in terms of continued productivity of clients who remain able to work and those who have fewer days lost from school or employment. In addition, clients are able to continue functioning in such important roles as parents and homemakers.

Additional and substantial cost savings can occur when an integrated treatment plan is used to link various service providers, including primary health care providers. Early intervention and preventive services can lead to the type of savings associated with preventive medicine. AOD intervention offered in coordination with health care networking may ensure less complicated medical treatment and reduced comorbidity. IOT programs can easily be organized as a component of care within a health care system.

Consumer Benefits

In contrast to traditional inpatient treatment, IOT allows services to be provided at times that are convenient to clients. The flexible program design of IOT also allows the provider to tailor services in response to regional variations and the needs of special groups, both in terms of core elements of the program and the special services that may be added to existing programs. The special accommodations that can be provided to patients make IOT an attractive option, especially in situations requiring flexibility.

Clients may view confidentiality as less of an issue in IOT settings, because unlike in inpatient settings, clients are not separated from their daily milieu -- thus avoiding protracted absences from work or family. Furthermore, an IOT approach avoids the disincentive to seek treatment that is often experienced by patients when the only AOD treatment choice is hospitalization. Flexibility, reduced barriers to seeking treatment, and enhanced confidentiality all serve to increase self-referral and utilization of this level of care.

Clinical Benefits

Increased duration of treatment. Among the many advantages of IOT is the increased duration of treatment. This allows for a prolonged opportunity to engage and treat clients while they remain in their home community. IOT provides for an increased opportunity for patients to practice newly learned behaviors. Clients in IOT are given sufficient time to incorporate new identities as recovering people with extended support, such as enhanced opportunities to become part of a fellowship of recovering people. IOT sets the stage for continuing outpatient care, which further increases the likelihood of successful recovery; the longer patients remain in treatment, the better the prognosis for full recovery.

Flexible levels of care. The severity of addiction and the intensity of symptoms vary among patients and vary over time for each patient. Generally, people require more intense treatment initially, followed by progressively less intense care. However, problems such as relapse, medical and social crises, and the emergence of psychiatric or subacute withdrawal symptoms demand a temporary increase in treatment intensity and/or level of care. IOT provides significant clinical flexibility that can be used to respond to clients' individual treatment needs -- especially when these needs change over time. Thus, as a client's treatment needs become more or less intense, the IOT program can likewise increase or decrease the intensity of treatment for that individual.

Increased patient caseload levels and improved patient retention. When staffed appropriately, IOT programs can usually treat a high volume of patients. A larger patient population makes it easier to create groups devoted to special issues such as incest, sexuality, anger management, and relapse. The IOT structure, which relies on a team approach and a therapeutic milieu, may result in a higher retention rate than low-intensity outpatient treatment. This means that staff can spend more time on effective caseload management. The flexible nature of the IOT setting also permits the ability to modify the structure and character of special issues groups.

Daily application of learning. IOT promotes the daily application of what is learned in treatment. Clients can put into immediate practice the coping strategies needed to adapt to living without AODs. They learn to confront daily challenges -- indeed, they must do so. New behaviors are learned within the context of the client's normal existence and environment, rather than according to prescribed strategies that are learned within a sheltered environment and only later, after discharge, put into practice. Changes can be made and supported incrementally and on a daily basis, thus providing an increased likelihood for permanency. Rather than having a hiatus from life in the "real world," the client in an IOT system must face the daily challenges posed by recovery. Changes thus become internalized, applied components of the client's life.

Community-centered support. Because IOT programs promote treatment that is patient-driven and centered on the whole person, they can assertively address problems related to family and work and to social, psychological, and emotional well-being. Psychosocial supports from family, employer, and community can be readily established or reestablished with an outpatient treatment experience. Clients are in a good position to confront challenges because not only have they learned new behavioral and cognitive responses to cravings, and have had real-life opportunities to practice relapse prevention techniques, but they also have an established community-based support network, including family and employer involvement with the IOT program.

Relapse management support. Because of the daily contact with patients afforded by IOT as opposed to traditional outpatient treatment, relapses can be addressed during early stages, often before actual AOD use. The approach of most IOT programs is to view relapses less as failures and more as evidence that changes are needed in the patient's treatment goals, lifestyle, and/or social systems. In IOT, clients can usually identify relapse triggers and issues with ease since they have real-world experiences to draw upon. When relapses do occur and when they are framed as potentially positive learning experiences rather than as stigmatizing episodes, the likelihood of patients remaining in treatment is heightened. Clinical assessment of the severity and duration of the relapse is essential.

Patient responsibility. Since clients are responsible for their participation, passive participation is difficult in IOT programs. IOT tends to empower clients, who must develop incentives to keep returning to treatment. In IOT, clients are less able to be reluctant or resistant observers. Personal responsibility is thus placed squarely on clients' shoulders.

Enhanced self-help participation. Self-help resources such as Alcoholics Anonymous and Narcotics Anonymous (AA and NA) are often essential to patient recovery during and beyond the IOT level of care. A special advantage of IOT is that clients can establish relationships to the community self-help support programs that they will likely rely on for extended support. Rather than identifying local groups after the completion of inpatient treatment, patients can be settled into an appropriate community-based resource prior to their completion of intensive treatment.

Enhanced therapeutic milieu. IOT programs offer patients the opportunity to develop relationships with other clients that can be readily fostered and maintained throughout and beyond the treatment experience. Clients can relate to one another outside of the parameters of the program. Since they likely live close to one another, they can continue mutual support once IOT is completed.

Problems and Challenges

IOT is a level of care that exists within the broader continuum of care. As such, IOT has limitations, disadvantages, and potential problems. Chief among these challenges are problems associated with the retention of patients, reimbursement and related financial concerns, and the management of acute crises.

It is possible for an element of IOT that generally provides significant strength to occasionally become a disadvantage. For example, participation in treatment while living in one's normal environment provides daily opportunities to practice relapse prevention and drug refusal skills. However, this arrangement also provides daily opportunities to encounter numerous social, environmental, and emotional triggers for drug craving and relapse. Like all other medical and psychological interventions, IOT involves both benefits and risks. Thus, patient placement in IOT must be considered in terms of costs and benefits.

Advantages of IOT Programs Over Inpatient and Typical Outpatient Programs

  • Reduced financial costs over inpatient treatment
  • Flexible, accessible services
  • Enhanced confidentiality over inpatient treatment (clients maintain usual routines)
  • Increased duration of treatment (better prognosis)
  • Clinical flexibility to respond to individual needs
  • Higher retention rate than low-intensity outpatient care
  • Daily real-world opportunities for clients to apply learned skills
  • Increased opportunities to establish community-based supports
  • Enhanced treatment for relapse
  • Greater patient responsibility
  • Participation in local self-help groups from the outset of intensive treatment
  • Enhanced ability to develop long-term supportive relations with other clients.

Retention Problems

One of the challenges of IOT relates to client retention and completion of treatment. The potential for encounters with drug craving cues and triggers, the potential for exposure and access to AODs, the lack of insulation from family and social crises, and the absence of supervision during nontreatment hours may contribute to retention problems.

While physical health is often the last aspect of health to deteriorate because of AOD addiction, it is often the first aspect to return to normal. Many patients equate restoration of physical health with being "cured." Thus, as some patients begin feeling better physically, they may feel that no further treatment is necessary.

Thus, clients in an IOT program should be exposed to assertive education and training about triggers, drug refusal techniques, handling social and emotional crises, feeling "cured," and after-hour peer-support and self-help programs.

Reimbursement Issues

The financial challenges inherent in IOT stem from the fact that it remains a relatively new approach. Problems in this area are related to definition, reimbursement, standardization, resistance within the AOD field, and competition with inpatient programs. The introduction of IOT comes at a time when payers are skeptical of providers and when there is an increased demand for reduction of health care costs. Overall, there is less experience with program and fiscal management of IOT programs, and third-party reimbursement for IOT services can be difficult to secure. The use of nonuniform admission and placement criteria further complicates the reimbursement issue. Additional difficulties may be posed by the relatively low profit margin experienced by many IOT programs, and the constant demand for a stable and high census. In some cases, a minimum number of days are required for reimbursement. Reimbursement may be lost for the whole week if a patient misses a certain number of days.

It is difficult for IOT programs to operate at a cost-effective level of utilization if too few clients are enrolled. In addition, the high flexibility of IOT programs makes it difficult to project revenue. Chapter 6 describes problems that relate to reimbursement and managed care.

Crisis Management

While in treatment, patients often lack coping skills to adequately deal with psychological, social, and medical crises. Given the complexity of AOD patients and the emphasis on reduced costs of care, patients in IOT are often at risk for complications. The IOT level of care provides less control over acute patient management problems. An important example is the fact that clients typically experience acute crises during after-hour periods. For this reason, it is recommended that IOT programs provide 24-hour crisis intervention services.

Problems and Challenges Within IOT Programs

  • Risk of relapse heightened by uncontrolled environmental factors
  • Less insulation from family and social crises
  • Absence of supervision during nontreatment hours
  • Increased difficulty of obtaining third-party reimbursement
  • Less control over acute patient management problems.

Treatment Components

IOT programs for AOD abuse will differ with regard to the number, type, and intensity of treatment services provided. Indeed, treatment services can be categorized into core, optimal, and enhancing elements.

  • Core elements. All IOT programs should have certain core or minimal treatment services. These include screening, assessment, treatment planning, 24-hour crisis management, pharmacotherapy, individual and group therapy, client and family education, case management, toxicology screening, and program outcome evaluation.
  • Optimal elements. IOT programs that provide more than the basic or minimal treatment services exist on a continuum that ranges from "complete" to "enhanced." These optimal elements include family therapy, childcare and transportation, recreation and leisure, continuing care, alumni activities, and outreach efforts in the community.
  • Enhancing elements. Programs may provide treatment services that can be described as adjunctive therapies. These optional elements include psychodrama, stress reduction techniques, acupuncture, biofeedback, art therapy, and other therapeutic services.

Core Elements

There are several minimal elements that are essential to the effective operation of a basic IOT program. While inclusion of all of these elements will not guarantee effectiveness, the implementation of these components ensures that certain barriers to effective care are removed. Describing them as core elements is based primarily on clinical experience. Vigorous research and examination are required to determine which of these elements indeed makes a difference in the experience and outcomes of clients treated in IOT. Although individual program configurations and target client differences can restrict and influence the way in which some treatment services are organized and provided, the following treatment services should be considered critical for IOT programs.

Program Leadership

The management and administration of an IOT program should provide leadership through the development and expression of a program mission, philosophy, and development plan. Further, program management and administration should ensure that the program has the financial and philosophical support to successfully meet its mission, goals, and objectives.

An IOT program requires planning, coordination, and evaluation of service delivery, including the maintenance of essential linkages with payers and referral sources. Good program management fosters continuous quality improvement and is required for financial planning and management. New opportunities for program expansion and improvement must be continually identified, as should changes in regional and national trends in AOD abuse and treatment.

Program administration should be organized in such a way that the program can proactively deal with the changes and challenges of the times. A key responsibility of program management is to provide a working environment that enhances staff productivity. Human resources support should be organized to meet the needs of the work force in order to ensure a successful and healthy operation (see Chapter 4 for discussion of staffing issues).

Screening

Screening for AOD abuse and dependence is a treatment service that identifies whether an individual is appropriate for an AOD abuse assessment. An initial, brief screening of a potential patient may be done during the first phone contact or through a scheduled or unscheduled walk-in. During this initial screening, basic data are gathered and the individual is encouraged to participate in an assessment if appropriate.

Some people can be screened out as inappropriate for IOT without their ever coming in to the program. In these instances, clients should be referred to appropriate resources. To the extent possible, medical emergencies should be screened and the client should be given a brief overview of the services provided by the program. The purpose of this initial screening is to determine whether the individual is likely to be an appropriate candidate for the program according to clear, previously determined admission criteria that include guidelines on clinical and financial eligibility.

There are several purposes and reasons for providing AOD abuse screening. They include:

  • Determining the need for an AOD assessment
  • Ensuring immediate placement in the appropriate level of care
  • Responding to communications from referral sources, self-referrals, families, and others about the potential for AOD treatment
  • Engaging and involving the referral source with the treatment program and the treatment process
  • Documenting information gained during crisis interventions and assisting clients to reach other levels of care such as emergency room treatment
  • Scheduling appointments for assessment and preparing patients for the assessment process.

It is recommended that clinical staff be involved in front-line AOD screening. Nonclinical staff are appropriate for answering questions about the program or for the registration of clients, but they should not be placed in a situation that involves clinical judgment.

When initial contact is made with a potential client, staff members handling the contact should realize that, although the call or visit may be routine for them, this initial step has enormous implications for the client. He or she may experience feelings of fear, anxiety, rage, apprehension, resentment, or ambivalence. Staff should be sensitive to the highly charged emotional set that is typical of many clients when they first contact a treatment site. It is important to congratulate people who contact an AOD program (whether for themselves or for others) for taking such an important step.

Assessment and Intake

Once a potential client has been screened, an assessment should be arranged as soon as possible if the person seems to be an appropriate candidate for the level of care provided by the treatment program. The goal of the assessment process should be to determine the individual needs of each patient through the completion of a diagnostic evaluation and to confirm the appropriateness of participation according to the program's admission criteria. The initial assessment should provide a complete psychosocial profile of each person, including all problem areas such as AOD use; psychological, physical, legal, and vocational problems and issues; and family and other social relationships.

An alliance should be successfully reached with the client prior to completing the assessment interview. Also, clients should be informed about confidentiality regulations and other informed consent issues. Both of these will help to promote a trusting relationship between the client and the program staff.

There should be a mechanism for immediate, same-day involvement in the program so that clients can be placed in treatment at the earliest opportunity. Encouragement and positive reinforcement for clients' participation are required throughout this process. Those for whom medical stability is in question should be examined by a physician prior to admission. It is advised that patients receive a physical examination within the first days of treatment when possible. This will ensure that medical issues are appropriately addressed in the treatment plan. If the assessment reveals that a client is inappropriate for participation in the IOT program, the program is responsible for linking the client with an appropriate level of care.

Procedures for registering clients should be developed to ensure their appropriate transition from the assessment to the assigned level of care. It is useful to collect financial information prior to the assignment, to ensure availability of services and appropriate placement.

Intake and registration procedures should include patient education regarding program policies and procedures, rules and regulations, expectations and rights, program schedules, the consequences of noncompliance, the use of AODs during treatment, the role of toxicology screening results, and the extent and limits of confidentiality.

Assessment within AOD treatment is a comprehensive, multidimensional process. Readers are referred to related TIPs for further clarification of the assessment of AOD abuse disorders. These TIPs are Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents; Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse; and Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System.

Toxicology Screening

Routine and random drug testing of body fluids for AOD use is essential to any IOT program. Screening should be performed randomly and perhaps as often as once a week, especially at the beginning of treatment. In some cases, asking clients to submit to screening more than weekly may prove beneficial.

Toxicology screening benefits patients by providing additional structure in terms of relapse prevention and fosters honesty about relapses by reducing patients' ability to manipulate the IOT staff, their employers, and other people in their lives. Screenings can help to reduce clients' ability to minimize or deny AOD use. All clients must be taught that the purpose of toxicology testing is to enhance accountability, to help maintain a drug-free environment, and to help achieve treatment goals. Screening also serves as a measure of client progress with respect to abstinence. Toxicology screening has other functions that relate to counseling issues -- such as confronting clients who claim to be abstinent with urine tests that are positive for AOD use.

Patients must provide written informed consent regarding who, outside of the program staff, may have access to or be informed of toxicology screen results. The measures taken to address positive screening results should not be punitive, but at the same time, patients should understand that some consequences may be outside the control of the program or the therapist.

If the results of toxicology screening are to be used for other than strictly internal purposes, the method used must meet requirements for certification by the National Institute of Drug Abuse and the Clinical Laboratory Improvement Act. When providing urine samples for analysis, clients should always be supervised ("observed urines") to reduce the opportunities for falsification. This is particularly critical when urine samples are used for legal or employment purposes. Appropriate procedures should be developed regarding the safe collection, handling, storage, and testing of urine samples.

Treatment Planning

There is nothing unique about treatment planning in an IOT program. Rather, treatment planning should follow the standard of care for AOD treatment in general. Based on the findings of the assessment, goals are established for an individualized master treatment plan that describes specific goals and actions to be taken. The treatment plan is a comprehensive and evolving record of treatment goals reflecting the client's cognitive, emotional, social, physical, and behavioral changes.

The treatment plan should be based on the patient's expressed objectives and on findings from the initial assessment, medical examination, toxicology screenings, and the biopsychosocial assessment. Specific, measurable goals that the patient agrees to accomplish during the course of treatment should be identified in the master treatment plan. The treatment plan should be developed by the treatment team and the patient together; it should be updated and reviewed regularly to ensure that it reflects the patient's progress toward established treatment goals and to identify new problems that require treatment. The treatment plan should serve as a "road map" for the treatment providers and the client, so that everyone understands "where the client intends to go and how the client will get there."

A treatment contract can be a part of the master treatment plan. It is a useful tool to address problems that arise throughout the course of treatment. A treatment contract consists of specific behavioral commitments to which the patient agrees. It can provide structure and support to the patient.

24-Hour Crisis Management Services

Because clients' problems do not typically conform to the working hours of the IOT service, arrangements must be made for clients to have access to emergency services and counseling support on a 24-hour basis. In smaller programs, this may be accomplished by agreements with existing services such as hotlines, crisis intervention services, and hospital emergency rooms. Larger programs that offer comprehensive addiction services may provide crisis intervention services through on-call specialists connected to an answering service and/or a paging system, or through the utilization of staff members who work in residential programs.

Pharmacotherapy Services

Pharmacotherapy services include the medical management of withdrawal, pharmacologic interventions such as methadone and naltrexone, treatment of psychiatric disorders, and treatment of medical problems including HIV and AIDS. Pharmacotherapy should not be a stand-alone service, but should be integrated with other treatment services.

Pharmacotherapy should be available for patients who require support through ambulatory detoxification, anti-craving and anti-addiction medications, and psychotropic medications to manage psychiatric disorders, as well as for HIV-positive clients who require antiretroviral therapy and other medications. Although some programs may elect not to use anti-craving and anti-addiction medications, it is essential that patients with major mental illness be maintained on appropriate psychotropic medications.

Ideally, the outpatient use of prescribed psychoactive substances will be carefully monitored on site, or possibly by other arrangements such as regular visits to the patient's physician or a mental health clinic. The coordination of such services is critical, and prescribing physicians should be integral or extended members of the treatment team.

For in-depth discussions of issues related to pharmacotherapy in addiction treatment, the reader is encouraged to read the TIP on State Methadone Treatment Guidelines. Also, the TIPs Meeting Patient Needs in Opioid Substitution Therapy: Matching Patients to Treatment Services and Detoxification from Alcohol and Other Drugs are scheduled for publication in 1994.

Individual Counseling

In the past, counseling has often been distinguished from therapy in that individual psychotherapy generally refers to a therapeutic attempt to help clients identify self-defeating patterns of behavior and unconscious motivations for specific behaviors. Psychotherapy often was organized toward the resolution of long-standing conscious and unconscious conflicts. Counseling in an AOD setting generally describes a therapeutic attempt to help patients solve specific acute problems that are barriers to complying with or benefitting from AOD treatment. Although extended examination of developmental and unconscious issues are not discouraged, brief interventions are seen as preferable to long-term individual work because of cost considerations. Particularly during the early stages of treatment, individual and group counseling sessions are valuable tools. Individual counseling can help:

  • Maintain clients' participation in the treatment process by continual review and clarification of treatment goals and objectives
  • Reassure clients about fears and anxieties that are an expected part of the behavioral change process
  • Enhance retention of clients in the program by strengthening the client-counselor relationship
  • Identify new and healthy responses and solutions to stressful and difficult situations.

Individual counseling provides the basis for a clinical relationship that will be sustained throughout the course of treatment. Multiple sessions of individual counseling, even if brief, are important in developing a solid therapeutic relationship between the patient and the counselor.

Individual sessions can be used to address routine issues that do not benefit either the client or group members by discussion in a group setting. Conversely, in individual sessions, clients often disclose certain issues -- particularly those around which guilt or shame is experienced -- that could be beneficially addressed in a group setting. Clients should be gently and sensitively encouraged to present such issues in a group setting, thereby defusing the emotional power of the issues and helping clients gain reassurance from peers.

Group Therapy

Group therapy is a standard component of addiction treatment and should be provided by a qualified clinician utilizing group processes and dynamics to facilitate the treatment process. Certain patients may not be immediately prepared to tolerate or work effectively within a group. Appropriateness for group therapy should be considered by the treatment team before patients are admitted to group therapy situations. Before participating in group therapy, clients should be oriented regarding appropriate behavior in the group, and other group rules should be explained, such as those associated with attendance, participation, honesty, feedback to others, and confidentiality.

People who are addicted to AODs tend to isolate themselves and grow alienated from others. Group therapy serves to break down isolating tendencies and gives clients a reference point from which to explore the fears and anxieties they experience as they contemplate a drug-free lifestyle. The dynamic of peer confrontation and support can be fully experienced only in a group setting.

Often the more experienced members of a group can anticipate and identify the pitfalls and experiences that may be expected during the recovery process for less experienced clients. Also, group norms help establish healthy recovery patterns (Yalom, 1985). Further, the quality and strength of the therapeutic milieu usually reflect the work clients do in group therapy.

Some group sessions should focus on here-and-now issues such as the desire to use AODs, recent relapses, struggles with potent emotions, or conflicts with other group members or family members. Other examples of special group topics commonly addressed in IOT programs include incest and abuse, gender or cultural issues, family relationships, and sexual orientation. Group sessions that are more cognitively oriented or psychoeducational are different from group therapy. Such education groups are another important component of IOT.

Ideally, therapy groups do not include more than 12 patients and are facilitated by two therapists. Although not always feasible, IOT programs should consider the advantages of dual-therapist groups, including role modeling, coverage during the therapist's absence, and strategic facilitation.

Education Services

The didactic presentation of information on addiction and recovery is considered an educational service. These educational programs, like those offered in individual or group settings, are designed to address core issues of human behavior and development associated with addiction and recovery. Some of the topics covered in educational sessions include:

  • The dynamics of addiction and the addiction process
  • The role and process of treatment and recovery
  • Medical aspects of addiction
  • The importance of abstinence from alcohol and all other drugs
  • Appropriate use of prescribed and over-the-counter drugs
  • Powerlessness and unmanageability of AOD use
  • Maximizing the use of self-help and support groups
  • Spirituality and the development of an externalized source of support
  • The roles of nutrition, exercise, leisure, and recreation in recovery
  • Experiencing emotions and feelings without AODs
  • Relationship skills
  • Sex and sexuality and recovery
  • Conflict resolution and confrontation skills
  • Family dynamics of addiction
  • Healthy relationships and family functioning
  • Relapse management skills
  • AOD refusal skills
  • Avoiding and defusing triggers for craving and relapse
  • Minimizing risks for HIV, AIDS, and sexually transmitted diseases.

Generally, this information is effectively delivered through small-group, highly interactive intimate discussions rather than in impersonal large-group lectures. Adjunctive activities may include handouts or writing assignments. Numerous videos and publications have been developed to support educational efforts. It is important that patient responses to these sessions be discussed. All educational programs should provide structure and time for productive interactive discussion and processing of the information being learned.

Providers of educational services should have mastery of their subjects and should avoid discussing subjects in which they are not well versed. Since patients rely on the accuracy and relevance of these sessions, the quality of these services is important. Consideration should be given to brevity. Generally, the normal attention span is 20 minutes, and presentations should be organized accordingly.

Family Education and Counseling

Family member participation is increasingly viewed as a critical area of AOD treatment. Didactic and experiential sessions should be provided for family members and significant others of patients enrolled in AOD treatment programs. These sessions help engage clients' families in treatment and enhance family members' understanding of the treatment and recovery process. Topics that might be covered in a family educational session include:

  • The dynamics of addiction, treatment, and recovery in the family
  • Relapse and relapse prevention
  • Family issues common in addicted families
  • Enabling and denial
  • Healthy family functioning
  • Healthy detachment and "tough love"
  • Communication and problem solving in the family
  • Management of family social functions
  • Introduction to Al-Anon, Alateen, and other relevant support systems for family members.

One of the purposes of family counseling is to educate family members about family dynamics and issues associated with addiction and recovery. Family counseling should provide the structure to support stabilization in the family and to assist the entire family in making changes that support the recovery of the client and all members of the family.

Family education and counseling provide an opportunity for family members to identify and address personal family dynamics and issues associated with the identified patient's AOD use and to develop solution-oriented strategies for change to support AOD recovery.

Self-Help and Support Group Orientation

Patients benefit from involvement with the 12-step programs and other self-help resources both during and after intensive AOD treatment. Studies have shown that those who participate in 12-step self-help groups such as Alcoholics Anonymous have higher rates of abstinence than those who do not (Hoffman and Harrison, 1988). The rates of abstinence are higher still among people who participate in aftercare plus Alcoholics Anonymous (Hoffman and Harrison, 1988; 1988a; Hoffman and Miller, 1992).

In many ways, self-help participation is the bridge between acute treatment and long-term recovery. IOT programs provide a limited number of treatment hours per week, and treatment continues for a limited time thereafter. Participation in self-help and other support group activities is vital to ensuring extended support beyond the treatment episode. The 12-step programs -- Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous -- are widely known as the self-help resources that best support sobriety and recovery.

Patients should be informed that there is variability among 12-step group meetings. For instance, some AA meetings are open to everyone, while some are open only to people who have the desire to stop drinking. Some meetings are open to a specific group of people. There are 12-step meetings attended only by men, women, gay men, lesbians, the hearing impaired, Spanish-speaking people, elderly people, people with AIDS, or nonsmokers. In many areas, there are 12-step meetings for impaired medical professionals and "double trouble" groups for clients with dual disorders.

Some 12-step meetings are regular (discussion) meetings, while others focus on the 12 steps ("step meetings"), and some feature people talking about their experiences with AODs and recovery ("speaker meetings"). Clients should understand the variety of options available in their community and know how to gain access to them and what to expect during the meetings. Clients should learn about the traditions and services associated with these programs, such as concepts of sponsorship and service to others. Clients should be encouraged not only to attend but to actively participate in the meetings. All clients should be provided with a meeting directory of 12-step groups.

Staff members should receive training about the predictable resistances that patients often have when introduced to self-help participation, especially resistance regarding the spiritual focus of many of the 12-step programs. IOT staff members should be sensitive to the need for matching individual patients to a "home group" of people with similar backgrounds, culture, and experience. A special advantage of IOT is that patients can identify and participate in their home group before leaving treatment.

Although the 12-step programs are the most numerous and accessible self-help resources available, they are not the only source of self-help support. While some people will reject the 12-step programs as part of an overall rejection of AOD treatment, some people will reject the 12-step programs in favor of alternative self-help resources. AOD treatment staff should be willing to help such clients explore reasonable alternatives that will genuinely help them establish and maintain sobriety and promote emotional and spiritual growth. The effectiveness of the self-help experience should be based on the client's comfort level and assumed benefit rather than on the experience or traditional outlook of the treatment provider.

AOD treatment staff should be familiar with alternatives to 12-step programs that may be available in their area, such as Rational Recovery Systems, Secular Organizations for Sobriety (Save Ourselves), and Women for Sobriety. There are also self-help groups that have a specific religious orientation such as Overcomers Outreach (for Christians) and the self-help group named Jewish Alcoholics, Chemically Dependent Persons and Significant Others.

Case Management Services

IOT programs should have arrangements or agreements with other organizations for delivery of support services not provided by the treatment program (such as vocational rehabilitation, social services, and employment services). The case manager links the client with these other services, manages the client's treatment plan, and ensures the client's appropriate legal consent. Programs treating individuals with children should also provide or have reliable linkages to child care services.

For clients to benefit fully from IOT, issues identified in the biopsychosocial assessment need to be addressed. Linkages should be provided to services called for in the master treatment plan, such as primary health care, job skills, child care, vocational and educational training, and transportation to and from the treatment site. Case management functions include securing the linkage and followup to ensure the provision of these services or of alternative services and monitoring this process until the identified need has been addressed. The absence of these critical services can create barriers to effective treatment. For example, not having child care makes it impossible for some parents to participate in treatment and family services. As the treatment field advances in its effort to provide whole-person care, and as clients continue to present with significant complications and special needs, case management services will be increasingly important in the treatment of AOD disorders.

Discharge and Transitional Service Planning

To ensure that the recovery process continues beyond the point of intensive treatment, a continuing care plan should be developed by the patient and the therapist. The objectives and goals identified during the initial phases of treatment are carried forth in this written plan, which specifies the activities and objectives that will enable the client to sustain abstinence and a recovery-oriented lifestyle. Issues left unresolved should be addressed in the continuing care treatment plan.

Transition planning consists of preparing the client for completion of intensive treatment and developing plans for the client's ongoing support for recovery. These plans should be established early in the treatment process and may include outpatient services, group counseling, vocational training, ongoing individual or family therapy, and/or self-help group participation.

Program and Outcome Evaluation

Evaluative studies are critical in determining an IOT program's effectiveness as measured by factors such as completion rate, abstinence, quality of life, employment and workplace stability, and reduction or cessation of criminal behaviors. Outcome evaluations assist the program to identify its rates of positive versus negative outcomes and to develop new and innovative services. Outcome evaluations should not be used as a punitive tool, nor to determine salary or pay scales. Rather, they can be used to point out performance issues that require ongoing staff training and to identify those intervention services that best help the addicted patient.

It is clear that the treatment of clients for AOD abuse is a difficult business. Programs should be careful in developing standards of care to identify fair and reasonable outcome indicators. Lifelong abstinence of graduates, for example, would not only be too ambitious to study but would also prove to be an unreasonable expectation. At the very least, it is recommended that IOT programs track patient retention and completion rates and related variables.

Optimal Elements

The planning, development, staffing, and allocation of resources for IOT programs should be approached with the specific goal of meeting the treatment needs of the target population. Therefore, it must be decided what treatment needs patients are likely to have before decisions are made about the types of treatment services that will be offered. All IOT programs should have the core elements described in the previous section. Depending on the mission and scope of specific IOT programs, many will require the elements described below as optimal elements.

Core or Minimal Elements of the IOT Level of Care

  • High quality leadership and administrative support
  • AOD screening
  • AOD assessment
  • Intake and registration procedures
  • Routine and random toxicology screening
  • Treatment planning
  • 24-hour crisis management
  • Pharmacotherapy and medication management
  • Individual counseling
  • Group therapy
  • Education about AOD issues
  • Family education and counseling
  • Self-help and support group orientation
  • Case management services
  • Discharge and transitional service planning
  • Program and outcome evaluation.

In other words, while certain AOD treatment services can be considered core elements that constitute the minimal elements for an IOT program, and other treatment services can be considered optimal elements that help to define an enhanced IOT program, certain so-called optimal elements can be considered core elements when they are required to meet the needs of the target population. For example, an IOT program that primarily treats single gay men without children who live in a specific neighborhood may not need child care or transportation services. In contrast, a program that primarily treats working mothers who are dispersed throughout a larger area may define child care and transportation services as core elements. Although it may not be realistic or necessary for all IOT programs to offer the complete array of core and optimal elements that are recommended in this TIP, all programs are encouraged to consider these services.

Outpatient Withdrawal Management

The medically supervised management of AOD withdrawal on an outpatient basis can be a valuable service of an enhanced IOT program. There is increasing evidence that withdrawal from AODs can be safely and cost-efficiently managed on an outpatient basis. To support this function, IOT programs are advised to secure or coordinate with appropriate medical resources to ensure that patients are served in the least restrictive level of care. Daily or near-daily withdrawal monitoring must be supported by an array of services, including individual and group counseling as well as nursing and physician services. This should not be a freestanding function, but must be linked with appropriate support services.

Family, Marital, or Couples Therapy

Therapy with a client's family, spouse, or significant other may be provided to address treatment and recovery issues as they relate to family dysfunction or problems in relationships with these individuals. In some cases, additional individual assessment and therapy with qualified professionals may also be appropriate during intensive outpatient treatment to explore issues that surface during treatment.

This type of assessment and subsequent treatment must be conducted by professionals with appropriate levels of experience, training, and supervision in family systems therapy. Such professionals should be well-grounded in treating family dynamics that are distorted due to AOD use in the family. Clients may require intensive family therapy to address long-term family dysfunction or issues related to family of origin. For this aspect of treatment, the family, in essence, becomes the patient.

Several treatment strategies can be helpful in addressing family issues, including: family counseling with a primary therapist, family education groups, and multifamily therapy groups.

Multifamily group therapy is a valuable treatment service for IOT programs. Bringing families together to share common experiences and issues can provide a tremendous opportunity for support and problem solving. Families that participate in multifamily therapy may feel less isolated and alone in their struggles. An extended milieu that includes family members can be established, often leading to supportive relationships beyond the duration of the program.

Special services to children of AOD-abusing clients may have particular benefit and should be considered if possible. It has long been known that the children of AOD abusers are at risk for AOD abuse, depression, attention-deficit disorder, and behavioral disorders.

Problems such as learning disabilities, sexual dysfunctions, or neurological impairments may impede or truncate the treatment process if not addressed.

Parenting Skills Training

One of the goals of AOD treatment for women with children is to help women keep their families intact -- unless they are abusing or neglecting their children. Indeed, compared with inpatient treatment, IOT may be particularly effective for stabilizing family relationships, since it allows patients to continue to function in their family roles during the treatment process (Longabaugh et al., 1983). (When IOT staff become aware that child abuse or neglect is occurring, child abuse and protection laws must be followed.)

Child Care and Transportation Services

In an optimal setting, access to child care is provided, either on site or by arrangement. Similarly, the transportation needs of patients can be met through bus, train, and subway passes or tokens, or staff drivers. State licensure requirements and liability insurance are considerations in implementing these services, as is having qualified staff to provide them. Addressing these issues can have a significant impact on patient participation and retention.

Organized Recreation and Leisure Activities

OT programs can be greatly enhanced by providing therapeutic recreation and leisure activities. Optimally, programs can hire a certified recreation therapist who has specific training in teaching recreation skills, leisure activities, and stress reduction, and who can educate patients about the role of such activities as an important aspect of recovery.

The value of recreational activities include: 1) learning social skills, 2) learning cooperation and trust, 3) experiencing healthy competition and teamwork, 4) bonding with other clients, and 5) learning to have fun without the use of AODs. Recreational activities that involve physical exercise often diminish agitation, stress, anxiety, and depression; increase appetite; and enhance healthy sleep. Recreational activities include aerobic exercise, organized sports and games, assorted arts and crafts endeavors, and therapeutic participant games.

Leisure activities include taking quiet walks, reading books, engaging in conversations, watching organized sports, and being passively entertained. In an IOT program, leisure activities can teach clients that some passive experiences can be therapeutic, healthy, relaxing, and enjoyable without the use of AODs.

Transition and Continuing Care Services

IOT programs should provide extended treatment services that follow the intensive phase of treatment.

Continuing care -- often called aftercare -- is the opportunity to address treatment plan goals and objectives that were not met during the intensive phase. Such services are designed to provide clients with continuing support and opportunities for further growth and development. Continuing care is also a transition from an intensive level of treatment to nontreatment phases of recovery.

Continuing care services can include such outpatient services as case management; individual, group, or family therapy; liaison and advocacy; and monitoring and drug testing. Continuing care can also include various social activities such as recreation and leisure events and field trips. The case manager, counselor, therapist, or continuing-care-monitoring specialist can provide valuable liaison services between the patient and the employer, union, judge, or probation officer as required. Such IOT program staff can observe and document participation and progress in treatment and provide evaluations to appropriate individuals or agencies when required.

If an IOT program is not organized to offer these transitional services, appropriate referral providers should be identified and used extensively. To ensure effective continuing care, IOT programs should develop a close relationship with those providers. Reimbursement for these services may be problematic. Because of the proven value of extended treatment participation, this matter should be carefully discussed with payers.

Alumni Activities

Activities that promote continued contact of former clients with the IOT program can be of benefit to both current and former clients in the program. Individuals who have completed treatment can serve as role models and peer helpers by bringing new patients to group meetings and by organizing special recreational activities such as picnics, parties, baseball games, and drug-free outings and social activities. Alumni events can provide patients with the sense of an extended or continuing therapeutic milieu and can offer important structure and support.

Outreach

Engaging AOD patients in treatment can often be a difficult and challenging process. IOT programs should consider providing a range of outreach services designed to: 1) encourage potential clients to participate in screening and assessment efforts, 2) minimize barriers to program intake, 3) provide education and interventions to families, and 4) motivate patients to engage and participate in treatment. Outreach services include satellite programs or services provided in areas easily accessible to patients. Outreach services also include visits by IOT staff or contractors to clients' homes, work sites, detention centers, inpatient units, or jails to provide screenings and assessments and other services.

Multiple contacts with the referral sources may be needed. Outreach services may be needed for both clients and families -- including home visits when possible -- to encourage clients to come to the treatment site, begin the assessment process, and address their feelings of ambivalence and fear about changing their lives.

When planning outreach services, IOT programs must be sensitive to confidentiality issues. Under the Federal confidentiality regulations, individuals who have applied for treatment services (whether followed through or not) are considered patients. Representatives from an AOD program cannot go to a patient's home or workplace without the patient's consent if the visit would reveal to others the patient's status as an AOD abuser. AOD programs must ensure that informed consent is obtained in instances when the patient's relationship to the program can be identified. See Chapter 7 for a discussion of legal issues for IOT programs.

Optimal Elements of the IOT Level of Care

  • Outpatient withdrawal management
  • Family, marital, or couples therapy
  • Parenting skills training
  • Child care and transportation services
  • Organized recreation and leisure activities
  • Transition and continuing care services
  • Alumni activities
  • Outreach.

Enhancing Services

There are several therapeutic interventions that can be valuable components of IOT programs -- as optional services that can enhance and supplement core services. Examples include:

  • Structured cognitive and behavioral interventions
  • "Ropes" courses
  • Psychodrama
  • Acupuncture
  • Biofeedback
  • Art therapy
  • Dance and other movement therapies
  • Vocational and legal assistance.

The availability of these services may depend on the specific client groups being treated, the geographic area, and funding considerations.

Clinical Challenges and Responses

While there are several advantages to IOT programs, there are specific challenges that are distinctive to the IOT level of care. The more common challenges are reviewed below and strategic responses are suggested.

Retention Problems and Relapse

Challenge. Unlike patients in residential treatment, those in IOT must make the daily decision to return to treatment. Further, IOT patients often live and work in environments in which substance abuse is prevalent and access to AODs is unconstrained. As they leave the treatment site, they may encounter environmental cues that trigger drug hunger and increase their risk for relapse. Factors contributing to client dropout include:

  • Ambivalence about stopping use of the primary drug of choice
  • Lack of commitment to stop all AOD use
  • Crises regarding family and work responsibilities
  • Denial of AOD problems or severity of the problem
  • Denial that adverse consequences are caused by AOD use
  • Discomfort with identity as a recovering person
  • Inability to relate with others in a group setting
  • Lack of family support for treatment and recovery
  • Family sabotage through enabling behaviors
  • Work schedule conflicts.

Clinical response. Patient dropout and relapse problems should be addressed through proactive interventions designed to engage and retain patients in treatment. Since many patients experience similar types of problems that can lead to relapse and dropout, programs should continually anticipate these problems, develop educational and therapeutic strategies to prevent them from occurring, and create specific plans to deal with them when they occur.

Many patients have been living in chaotic, high-stress, dysfunctional environments that promote isolation and distrust and encourage people to ignore their feelings and to medicate their emotions with AOD use. In contrast, IOT programs should provide an environment that is orderly and free of unnecessary stress, that encourages people to recognize and handle emotions without AOD use, and that teaches and promotes trust and interdependence.

Programs should use several techniques that encourage patients to become engaged in the treatment process and promote a sense of ownership of treatment and recovery efforts. For example, rewards can be created for perfect or excellent attendance in treatment, successful completion of treatment can be marked with ceremonial graduation events, and important treatment and recovery milestones can be acknowledged in client community meetings. Special events and activities such as staff-client skits and games can be organized and regularly scheduled. Such activities can help clients experience a sense of inclusion, belonging, interdependence, trust, openness, and emotional self-awareness.

Behavioral contracting can help improve retention. Methods include written agreements to complete the program and the use of a modified token economy point system. Programs can provide tangible incentives to foster additional motivation.

In a modified token economy system, patients earn points or recognition for such practical behaviors as arriving on time for the treatment day and attending all scheduled activities for the day. They can earn points or other recognition for completing a treatment plan objective, identifying a sponsor, completing the relapse prevention workbook, or working with the counselor to schedule a family session. In some cases, points are redeemable for bus tokens, daily meditation pamphlets, and 12-step literature that would otherwise have to be paid for (such as the "Big Book" of Alcoholics Anonymous).

Since relapse is one of the main reasons for patient dropout, IOT programs should provide clearly defined education and practice sessions on relapse prevention. These sessions should address: the process of relapse, relapse-related thinking and behavior, drug hunger triggers and subsequent responses, AOD refusal skills, and the use of self-help, recovering peers, and professional services for the prevention or curtailment of relapse.

Frequent AOD toxicology screening is recommended, particularly for clients with a history of relapse. Positive drug screenings should be immediately discussed with clients, and problem resolution strategies should follow these relapses. Aggressive encouragement of family involvement in treatment can result in: 1) active family participation, 2) family ownership of the treatment and recovery process, 3) potent family support of the client for treatment and recovery, 4) family recognition of early warning signs of relapse, and 5) unified family persuasion to remain abstinent and in treatment. These efforts help to decrease relapse and client dropout.

In group therapy sessions, excessive retelling of stories by patients about their AOD use should be prevented. Such "drugalogue" stories can glorify AOD use, generate euphoric recall, and become triggers for drug hunger and relapse. Instead, a positive therapeutic milieu can be developed to recognize and support recovery progress and to deter and confront "slips" or setbacks.

Early in the treatment process, consent should be obtained to allow the IOT program to contact clients' source of referral -- such as an employee assistance program professional or an employer, probation officer, or spouse -- so that these agencies or individuals can be contacted in the event of potential or actual departure against medical advice. AOD programs must have written consent from the client to contact the referral source; the client can verbally revoke that consent at any time. Also, the consent form must specifically state the reason for communicating with the referral source, such as "to discuss progress in treatment." When dropouts occur, referral contacts can help apply leverage to encourage clients to immediately return to treatment.

When patients do not arrive for treatment and scheduled appointments, outreach efforts should be initiated, such as telephone calls immediately after group sessions are missed. Again, the AOD program cannot disclose any information that will reveal the name or nature of the IOT program to the individual who answers the phone unless the patient has signed a consent form for that individual. Group members may also choose to check in with missing peers, and should be encouraged to do so -- within the guidelines of confidentiality regulations.

Followup with patients who drop out of treatment should be extensive and assertive, including phone calls, letters, home visits when feasible, and other forms of outreach -- for an extended period of time.

Treatment Noncompliance

Challenge. A lack of compliance or feeble compliance with the goals and objectives of AOD treatment occurs in all types of programs at all levels of care. The flexible nature of IOT and the amount of time spent outside of a treatment environment may make treatment noncompliance easier than more intense levels of care. Resistance or ambivalence to treatment may be manifested by intermittent attendance and minimal participation, refusal to attend self-help groups, avoidance of urine drug screens, refusal to sign consents, and missed appointments.

Clinical response. A clearly delineated list of expectations must be included in the master treatment plan, signed by the client at the onset of treatment, and referred to throughout the course of treatment. Other patients can be involved in the role of peer helpers to reinforce desired behavior. Recognition of desired behavior on the part of other clients in the program is also useful as a part of this reinforcement process.

As a last resort, therapeutic discharge, in which treatment is terminated and a referral made to another program, may be considered. Whenever this mechanism is employed, however, a means should be provided for the patient to reengage in the program.

Employer Mandates

Challenge. In most instances, the involvement of a client's employer has a positive effect on the overall treatment process, especially when an employee assistance program is involved. However, there are times when employer mandates and pressures placed on the patient by the employer are counterproductive to treatment goals. Employers may be unwilling to provide a flexible work schedule to allow employees to participate in treatment. Another problem is the lack of confidentiality at the work site, a problem that can make the client a target for discrimination by peer employees.

Clinical response. In some situations, involvement of the patient's employer in the treatment plan through education and frequent contact can help to make the employer an ally in achieving treatment goals. Again, this is especially true for clients who have an employee assistance program or similar body such as union committees. Indeed, IOT programs must be sensitive to the variation among employers and listen to patients that describe their employers as unsympathetic. At the same time, clients who have had multiple positive drug screens must be clearly told that they may face termination by the employer if the trend continues and that being in treatment is not necessarily protection against loss of employment. Utilization of employee assistance program services can greatly assist in the patient-employer relationship. Such services have clearly defined policies and provide supervisory training to business and industry.

Unhealthy Relationships Between Patients

Challenge. Most chemically dependent people come to treatment with a history of dysfunctional relationships, and the tendency to form such relationships does not automatically disappear upon entering treatment. Unhealthy and disruptive alliances, particularly romantic or intimate involvements, sometimes form among clients in a treatment program. Given the nature of the treatment environment and the emotional intensity of issues discussed in therapy groups, clients often can become intimately involved with other clients. Group therapy is inherently personal, and the risk develops for sexual relationships.

Among the problems engendered by unhealthy relationships between clients are resumption of AOD use, covering up for one another, sexual relationships, conflicts, and breaches of confidentiality. These relationships may or may not include AOD use, are nearly always brief and dysfunctional, and can lead to relapse for both individuals.

Clinical response. The therapy group can be used as a healing milieu to confront the individuals involved, but this should be done in a sensitive and cautious manner. A treatment contract can also be a useful tool to curb or prevent unhealthy alliances. As a last resort, therapeutic discharge may be considered, but patients should be confronted on a clinical level to gain an understanding of this behavior.

Recidivism

Challenge. As in any treatment setting, there may be clients admitted to IOT programs who do not gain significant benefit. Some have not made a commitment to the goals of AOD treatment and recovery, some live in extremely chaotic and dysfunctional situations, some have particularly severe AOD problems, and some have complex problems (such as combined psychiatric and AOD problems) that require clinically complex and intensive treatment.

Although these patients might derive greatest benefit from AOD treatment in a structured living environment, such resources do not always exist. Clients with these needs are at higher risk for recidivism, often with multiple admissions to the same or different programs.

Clinical response. Alterations in the treatment plan must be made according to individual clinical needs. One response to recidivism involves a tighter clinical control in the form of clearly defined admission and discharge criteria. Many patients at high risk for recidivism can benefit from contingency contracting in the form of a behavioral contract in which clearly specified rules and responses are described in specific behavioral and measurable ways. More frequent individual sessions and increased involvement of the client's family and community support system are also helpful.

Finally, any treatment program has to honestly examine itself and determine whether it is inappropriate for a particular individual. At times it may be determined that a patient would benefit more from another type of treatment or level of care. Significant efforts must be made for appropriate placement.

Family Conflicts

Challenge. Addicted clients are often part of families that are fragmented, loosely organized, dysfunctional, and characterized by anger and conflict. Family members often have poor communication and coping skills, and may be addicted themselves.

Some families may refuse to participate in treatment, disavowing responsibility for the problem. Patients may have to contend with active AOD abuse in the family and repeated opportunities and inducements to use AODs. They may have a sense of shame or embarrassment based on criticism by other family members of the decision to seek treatment.

Clinical response. Family engagement and education should begin as early as possible in the treatment process, preferably at intake. At the onset of treatment, clients should be asked to sign a letter specifying which family members can participate in treatment sessions with them. The client must also sign consent forms that permit the representatives of the IOT program to speak with these family members about treatment participation.

IOT programs can develop creative ways to engage family members, often utilizing staff and volunteer alumni and family members of alumni. Phone calls and home visits by family members of program alumni can be particularly effective ways to engage family members in the treatment process. Some programs have a paid staff member who creates and coordinates a volunteer network of family members of alumni, especially alumni spouses. These volunteers can invite other family members to Al-Anon meetings, provide education about AOD treatment and recovery, and provide education about recovery from codependency. The volunteers can provide friendship, fellowship, and encouragement for family members to support the AOD-dependent family member's treatment and to help with family problems such as codependency.

Multifamily therapy groups and couples therapy with several couples are also effective in garnering the support of family members. These are professionally led groups in which families, spouses, and significant others are brought together, with or without the client, to openly discuss real-life issues and to explore their own history and family dynamics. Additionally, 12-step self-help groups for family members, such as Al-Anon and Nar-Anon, are free and available in most communities. Involvement with these groups should be an aspect of family treatment participation.

Arriving Intoxicated

Challenge. It is inevitable, given the lack of control over patients' behavior outside of the IOT program, that some clients will occasionally arrive at the treatment site intoxicated.

Clinical response. The initial treatment agreement should state that patients will arrive in an AOD-free state and will not be allowed to participate in group sessions or to receive other services if they arrive intoxicated. When this does occur, however, a Breathalyzer test or a urine screen should be immediately administered.

If clients are found to be legally intoxicated, program staff can request to hold their car keys. Arrangements should then be made for safe transportation home. Programs should be sensitive to safety considerations for clients and liability implications for the treatment program if intoxicated individuals are allowed to leave on their own. (See Chapter 7 for a thorough discussion of legal and ethical issues.)

Indeed, programs should seek legal counsel for advice regarding the confiscation of intoxicated clients' car keys, and regarding clients who leave the IOT premises intoxicated. Some programs have a policy that involves anonymously calling the police to warn them about individuals not in a condition to drive who are nonetheless driving. They describe the car and give the license plate number and direction of travel; however, the patient's name the source of the tip, and the fact that the patient is intoxicated are not mentioned.

In the case of a belligerent or threatening client, or a client who appears to be experiencing psychedelic drug intoxication, the primary concerns should be for the safety of the individual, other patients, and staff. Staff should be trained to handle belligerent and threatening clients, and contingencies should be thought out in advance regarding containment of the individual.

Talkdown counseling should occur in areas that are quiet, with minimal stimulation, and free from interruption. However, a staff member counseling a belligerent or threatening patient should not be left alone in a closed room. Other staff members should unobtrusively monitor the proceedings.

It may be occasionally necessary to call upon law enforcement agencies to address and contain a potentially violent incident. It is not against the Federal confidentiality laws to request police help when a client has committed or threatens to commit a crime on program premises or against program personnel. Because the presence of police officers at the treatment site may be upsetting to other patients, the process by which such incidents will be handled should be negotiated with law enforcement agencies in advance.

Since the confidentiality of clients can be compromised, patients who are uninvolved with the incidents should be placed in areas that the police will not enter. Programs should establish a protocol for staff and client debriefing sessions following crisis events. These sessions will help staff with their reaction to crises, and help them assist clients with their reactions.

Managed Care and Reimbursement Restrictions

Challenge. Financial considerations often threaten a patient's ability to participate in treatment for the necessary duration of time. Unfortunately, a lack of understanding of the IOT level of care by some self-insured firms and payers, especially by managed care organizations, results in premature termination of treatment for some patients. At other times, it may not be discovered that funding is lacking until after the patient has begun treatment.

Clinical response. Every IOT program needs to have a policy regarding uncompensated care for clients who run out of funds. A clear financial assessment should be completed at intake and a contingency arranged for alternative sources of payment such as self-pay, Medicaid or Medicare, public sources, an extended payment plan, or second-party payment, such as payment by a family member.

The requirements of third-party payers or agents may have to be factored into the master treatment plan for a client whose benefit is managed. For instance, if it is known at the beginning of treatment that a client will be allowed only a certain number of sessions, an appropriate treatment plan should be established to ensure effective care within the bounds of the client's benefits.

It is never acceptable to discharge patients because of their inability to pay without arranging for treatment elsewhere. There should be no break in treatment when discharging a patient to another program. It is unacceptable for programs to abandon patients. Acceptance and admission of clients into an IOT imply responsibility for appropriate care.

Clinical Challenges in IOT Programs

  • Relapse and dropout
  • Treatment noncompliance
  • Employer mandates
  • Unhealthy relationships between clients
  • Recidivism
  • Family conflicts
  • Arriving intoxicated
  • Managed care and reimbursement restrictions.

Summary

The treatment components of an effective IOT program can be described as core, optimal, or enhancing elements. All IOT programs should provide the core treatment services of screening, assessment, treatment planning, 24-hour crisis management, pharmacotherapy, individual and group therapy, client and family education, case management, toxicology screening, and program outcome evaluation. IOT programs that provide more than basic or minimal treatment services may include optimal treatment components such as family therapy, child care and transportation, recreation and leisure, continuing care, alumni activities, and outreach. IOT programs may provide adjunctive therapies such as psychodrama, stress reduction techniques, acupuncture, biofeedback, art therapy, and other therapeutic services.

IOT programs have numerous advantages. These include extended duration of treatment at less cost than intensive inpatient treatment, with equivalent treatment efficacy. IOT programs provide a flexibility that is beneficial to patients and staff. Clinical benefits include the daily application of learning and relapse management support. The development of IOT programs should include attention to potential problems related to retention, reimbursement, and crisis management.

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